Section 4: treating the patient in pain.

Physicians may choose from a variety of pharmacologic and nonpharmacologic options to treat patients with painful rheumatic diseases. Osteoarthritis (OA) is the most common type of arthritis requiring pain management. New disease-modifying antirheumatic drugs and biologic response modifiers can improve disease states in patients with rheumatoid arthritis (RA). After the inflammatory component of RA is minimized with such agents, treatment goals shift to those similar to secondary OA and other degenerative joint diseases. Relief of pain and improvement in functional status are essential components of effective therapy. A pure analgesic such as acetaminophen and nonsteroidal antiinflammatory drugs, including the cyclooxygenase-2-selective inhibitors for those at risk for gastrointestinal side effects, may be used at the lowest effective doses. Combination therapy for acetaminophen and an opioid may maximize pain relief and provide greater speed and duration of action than the separate components. Use of the atypical opioid tramadol with acetaminophen often results in an improved side-effect profile compared with stronger opioids, with similar levels of pain relief. Adjunctive therapy with agents such as topical analgesics, intraarticular hyaluron, tricyclic antidepressants, anticonvulsants, muscle relaxants, and anxiolytics may also be helpful. Nonpharmacologic therapies such as exercise, physical therapy, and psychologic counseling may also diminish pain and improve outcome in patients with rheumatic diseases. One may also consider yoga, acupuncture, biofeedback, massage, relaxation techniques, and other alternative therapies.